Introduction:
Schizophrenia is a very complex clinical disorder, with a wide array of manifestations which include changes in perception, emotions, behaviors and thought. Symptoms of schizophrenia include positives, such as delusions, hallucinations, and catatonia, and negatives, such as flat/blunted affect, social withdrawal, impaired attention and anhedonia. Although many theories about dopamine and serotonin imbalance have accumulated, etiology of schizophrenia remains unknown.
Schizophrenia commonly peaks between ages 15-25 in males and 25-35 in females. Treatment is life long and is recommended among all diagnosed patients. Antipsychotics are first line of treatment but are also associated with many undesirable effects such as EPS.
There are several other disorders that share features of schizophrenia. Psychotic disorders that resemble schizophrenia but last less than six months is known as Schizophreniform and when a patient has symptoms of schizophrenia for more than one day and less than a month it is called a brief psychotic disorder. Schizophrenia along with symptoms of depression or mania is classified as Schizoaffective disorder.
Objective:
To write a case study on a patient with Schizoaffective disorder presenting with both depressive and manic episodes.
Methodology:
This patient’s data was obtained over the past 9 years with clinical interviews of the patient. The most recent clinical interview was held on October 18, 2017.
HPI:
Sean Burden, is a 34-year-old African American male with a past medical history of Schizoaffective Disorder (Bipolar Type), Somatization Disorder, OCD, Hypertension, and LADA presented to PACT Atlanta on 10/18/17 for a follow up. Patient was last seen 09/07/17. Patient is seen to be really obsessing with intrusive thoughts. Patient is at clinic with his mother, who spoke a lot throughout the session about her own problems and history.
During the patient’s last visit, patient reported increasing anxiety and depression. His Bupropion was increased to 150mg QD for relief of anxiety and depressive symptoms. Last Risperdal Consta 50mg IM injection was given 8/24/17. Another IM injection was given on 10/18/17.
Patient was last seen by Dr. Daniels in October 2017. Patient processed his thoughts/ feelings/ beliefs associated with both past and current life-events that traditionally lead to maladaptive behavior patterns. Patient discussed struggling with thinking he has AIDS, even though his tests have always returned negative. Clinician and patient discussed paranoia as part of patient's diagnosis and ways he can self-soothe and remind himself to believe facts/proof instead of buying into the paranoia.
Patient still believes he has AIDS even though all his tests have come back negative. He has also been continually obsessing about his blood glucose levels even though his A1c levels came back at 6.2. At that time, patient reported to feeling down and depressed.
Memory: Patient describes his overall memory as poor, but has had no problem with recent memory.
Concentration: Patient is obsessing over testing his blood glucose levels and believes he has AIDs.
Sleep: Patient gets six hours or less of sleep.
Appetite/ Energy: Patient has not noticed any changes. Patient is stable.
Therapy: Patient is currently in therapy with Dr. Cliff Daniels.
• Patient expressed that he continues to be stuck in his past and that it causes him to feel depressed and experience negative thought processes.
• Patient discussed having another argument with his brother and the fact that he was able to diffuse the situation. Patient asked clinician to help him develop healthy coping skills to lessen his anger.
• Patient processed through the argument he had with his brother 2 days ago.
• Patient discussed the abuse that he suffered by his father and how it currently affects his mood. He noted that his father is not going to change and that he needs to learn how to accept that.
• Patient discussed feeling sad about his birthday. He stated that every year right before his birthday, he believes that he is going to die. Patient was open to processing this concern.
• Patient utilized the session to process going to the funeral of a 1 month old infant and how it has affected his mood. Clinician and patient discussed the grief/loss process as the normal response to loss.
• Patient shared his homework assignment of writing about affirmations on a daily basis. Patient admitted to having some struggles with affirmations but admitted that they have encouraged him.
• Patient expressed that he experiences psychosis in the form of paranoia. Clinician introduced The Work" by Byron Katie to assist patient in challenging some of his beliefs/thought processes.
• Patient utilized the session to process how his brother's aggressive behavior responses affects his mood. Patient reported that his brother knocked his mother down this morning and that he was very angry as a result. Clinician and patient discussed steps to take to ensure that he and his mother felt safe in their home.
• Patient expressed that he and his brother have had bad arguments and that there is a lack of respect between himself and his brother. He admitted that it affects his mood and requested that clinician mediate. Patient, his mother and brother all verbally agreed to set and clearly state their boundaries. Patient stated that he will start asking for what he needs without being prompted to do so or waiting to see who will assume what he needs.
• Patient reported that he has thoughts of death constantly but he is not suicidal. Clinician and patient discussed thought-blocking as a way to not entertain negative thought processes. Patient and clinician discussed daily affirmations and patient wrote out 5 of them during the session to help assist in building his confidence and an elevated mood.
• Patient shared his history of abuse by his father. Patient shared that he experiences depression and anger as a result of what he endured as a child. Patient shared that he wants to learn how to let go of the past with regards to his father's abusive behavior towards him, his siblings and his mother. Patient reported having low self-esteem, most likely due to having thought insertions. Clinician explained patient's diagnosis of Schizoaffective Disorder.
Medications/SE: Pt states that he has been having a tremor or "the shakes" due to a SE from the medication. Pt does not feel like the Bupropion has been helping him.
Mental Status Exam:
Patient was noted to be an African American male looking his stated age. Patient is alert and oriented to person, place, time and circumstance. He appears appropriately dressed, with normal psychomotor activity. Patient has a self-contemptuous mood and appropriate affect with fluent but pressured speech. His thought process manifested as a flight of ideas, and his content was entirely about having AIDS. Patient denies hallucination but has delusions concerning his health. He continually thinks he has AIDs. Patient denied both suicidal and homicidal ideations. Patient shows poor insight and judgment. Patient has alert level of consciousness, impaired short-term memory, normal concentration, easily distracted, and no problems with sleep. Patient has had no changes in appetite or energy and has a low risk assessment.
Past Psychiatric History:
The patient began to experience difficulty around the age of 15 years, after years of being abused by his father and watching his father abuse his mother and siblings. He became angry, withdrawn from family and friends, talked less, had thoughts of suicide, and started feeling depressed. More recently, in October 2017, patient presents with delusions. He believes any time he sees an ad for AIDS, they are trying to tell him he has AIDS. He feels like the messages are all being directed at him.
Medical Problems:
No history of medical problems was noted.
Social History:
Alcohol Use: denied
Substance Use: denied
Domestic Violence: denied
Patient reports having grown up in an abusive home from his father, both physically and emotionally. He was conceived due to his father raping his mother. He strongly believes his father has 'put witchcraft on him' causing insomnia in 2003. Patient's father is still attempting to remain in contact with family after divorce in 2002, although they do not want to. Lives with mother and brother. Patient has a very bad relationship with father.
Family Hx:
Brother – schizoaffective disorder + MDD, abused by father
Mother – bipolar disorder, abused by father
Drug Allergies:
NKDA
Current Medications:
Depakote 500mg 1 tab pm
Trihexyphenidyl; 2mg 2 tab am, 2tab pm
Bupropion 150 mg 2am (150 total)
Invega Sustenna 234 mg IM
CMI 100 mg qhs
Metformin 1000mg, 1 tab qd
Propranolol 10 mg BID
Verapamil 80mg qd
Cholesterol Pill- patient does not remember the name
Differential Diagnosis:
1. Bipolar Affective Disorder- (also known as Manic Depressive Illness) characterized by periods of deep, prolonged and profound depression with alternating periods of an extremely elevated or irritable mood (manic episodes). Manic episodes consist of one week of mood disturbance which is characterized by elevation, irritation or expansiveness present with three of the following symptoms: distractibility, irritability/irresponsibility, grandiosity, flight of Ideas, activity increased with weight loss and increased libido, decreased Sleep, and talkativeness. Hypomanic episodes present with elevated or irritable mood for 4 consecutive days with 3 of the symptoms above. The major depressive episodes consist of two weeks of five or more of the following symptoms: depressed mood, markedly decreased pleasure/interest, significant weight loss or weight gain, hypersomnia or insomnia, psychomotor retardation, low energy/fatigue, feeling of worthlessness/guilt, decreased concentration, and preoccupation with suicide.
2. Brief Psychotic Disorder- characterized by abrupt onset of 1 or more of the following symptoms: delusions, hallucination, bizarre behavior, and disorganized speech. Patient may also present with affective symptoms, disorientation, catatonia, decreased attention, emotional instability, yelling or being very quiet, bizarre behavior, and impaired memory.
3. Depression- Patient presents with a normal appearance but with those with severe symptoms, a decline in grooming and hygiene may be present. Patients will present with psychomotor retardation, flat affect, and agitation. Patients will present with same two weeks of five or more of the following symptoms: depressed mood, markedly decreased pleasure/interest, significant weight loss or weight gain, hypersomnia or insomnia, psychomotor retardation, low energy/fatigue, feeling of worthlessness/guilt, decreased concentration, and preoccupation with suicide.
4. Psychosis due to substance abuse- Common cause of psychosis in the clinical setting is alcohol, sedative hypnotics, and illicit drugs. Risk is increased with cocaine, amphetamine, alcohol and hallucinogen use. Cocaine and amphetamines will cause psychosis symptoms. Alcohol causes delusions which cause the disorganized behavior, disorganized thoughts, and confusion. Schizophrenic effects of the drug will relatively decrease after the drug wears off, anywhere from days, months or years. Early symptoms of psychosis include delusions, hallucinations, changes in emotion, socially withdrawn, lack of motivation, disorganized thought/speech, and altered behavior (violent, erratic). Psychosis due to substance abuse was ruled out via history and UDT.
Diagnosis:
1. Schizoaffective Disorder, Bipolar Type- characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, along with symptoms of mood disorder such as mania and depression. Patients see or hear things that are not present, have fixed beliefs with no evidence, disorganized thinking, depressed mood and manic behaviors. The exact etiology of schizoaffective disorder is unknown but may be related to genetics (as it tends to run in families), brain chemistry/structure, stressors (death of a close one, divorce, and losing a job) and drug use. Diagnosis is clinical and treatment is based on pharmacotherapy with use of mood stabilizers, antipsychotics and antidepressants along with psychotherapy (CBT and family focused therapy).
2. Latent autoimmune diabetes- LADA is a form of type 1 diabetes mellitus that usually occurs in adulthood. It often has a much slower course of onset than type 1 diabetes in children. Adult with LADA are usually misdiagnosed as having type 2 diabetes. LADA is diagnosed based on hyperglycemia along with clinical diagnosis of islet failure than resistance. The diagnosis can be supported with low C-peptide levels and raised antibodies against islets of Langerhans. Patients with LADA are usually treated with oral medication of type 2 diabetes mellitus and when this fails patient will be switched to insulin treatment. Along with treatment, it is very important to monitor for long term complications.
3. OCD- characterized by symptoms of obsessions, compulsions, or both which can interfere with aspects of daily life including personal relationships, work, and school. Obsessions are repeated thoughts, urges or mental pictures that cause anxiety. Compulsions are repetitive behaviors that people perform in response to an obsessive thought. Patients are unable to control their thoughts/behaviors, spend more than one hour a day on thoughts/behaviors, get relief from anxiety by performing compulsions, and significant problems in their daily life due to these thoughts/behaviors. The etiology of OCD is unknown but can be caused by genetics, brain structure/functioning, environment, and infections such as pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). Treatment included pharmacotherapy with SSRIs or TCAS and psychotherapy with CBT.
4. Somatization Disorder- characterized by multiple constant physical complaints that are associated with excessive thoughts, feelings, and behaviors which are related to the symptoms. The symptoms are not intentional with or without and underlying medical illness. When a somatic symptom accompanies another medical disorder, patients overreact to the medical associations. Diagnosis is based upon the patients history and patient’s family. Treatment revolves around establishing a constant, supportive patient physician relationship in order to prevent the patient from getting exposed to unnecessary diagnostics test and therapy.
Assessment/Plan:
Patient continues to worry constantly and be obsessive about having AIDS. He is reaching an almost delusional height and intensity. The plan is to increase CMI to 150 mg qd. It may also be beneficial to increasing his Depakote due to his short-term decline in his overall cognitive functioning.
Medication Review:
Depakote- used to treat manic phase of Mr. Burden’s bipolar disorder
Trihexyphenidyl- used to treat involuntary movements due to side effects of certain psychiatric drugs. It belongs to anticholinergics that work by blocking acetylcholine, which helps decrease muscle stiffness, sweating, and saliva production. It helps stop severe muscle spasms of the back, neck and eyes along with EPS that are caused by psychiatric drugs.
Bupropion- used to treat depression. It can improve the patient’s mood and feelings of well-being. It works by restoring the balance of neurotransmitters in his brain.
Invega Sustenna- used to treat schizoaffective and schizophrenia. It is an atypical antipsychotic that decreases hallucinations and helps the patient thick more clearly. It allows Mr. Burden to fell less agitated and be more active.
Metformin- used to treat type 2 diabetes. It is used with proper diet and exercise to control high blood sugar. By controlling Mr. Burden’s blood sugar we help prevent kidney damage, blindness, nerve problems, neuropathy, MI and stroke. Metformin will help restore the body’s proper response to insulin produced by the body along with decreasing the amount of sugar your body absorbs and makes.
Propranolol- is a beta blocker which used to treat high blood pressure, irregular heart beats, and tremors.
Verapamil- is a calcium channel blocker which is used to treat high blood pressure. It works by relaxing the blood vessels which help blood flow more easily through the body.
Case Discussion:
Mr. Burden presented with a manic episode. His affect was irritable. He manifested with delusions concerned about having AIDS. He was also preoccupied with his blood glucose levels being high when levels were within normal. He had no insight, as demonstrated by his belief that Ads on Facebook or other online sources were telling him that he had AIDS. Based on his past history of schizophrenic, depressive, and manic symptoms, this patient is diagnosed with schizoaffective disorder. When Mr. Burden was 15 years old, he had a subacute onset of schizoaffective disorder which later developed into a full disorder. Patient mainly had negative symptoms and positive symptoms become more prominent in the past year. Even though patient had depressive symptoms it was not predominant. The patient’s experience with abuse from his father was his biggest risk factor to developing schizoaffective disorder.
Conclusion:
Schizoaffective disorder is two disorders combined into one. Schizophrenia and a major mood disorder, either bipolar or major depression, with mood symptoms being prominent for majority of the illness. Mr. Burden has had prominent mood symptoms for a large duration of his illness and continual since the onset of his illness. He also fulfills the next requirement for schizoaffective diagnosis which states that there has been a period of at least two weeks of schizophrenic symptoms in the absence of mood symptoms. He presented with a manic episode with a course which was typical of schizoaffective disorder. The best treatment for schizoaffective disorder are atypical antipsychotics because they acutely treat mania and help schizoaffective disorder in long term.
References:
Crawford, Michael. “Living with Schizoaffective Disorder.” Psych Central, 17 July 2016, psychcentral.com/lib/living-with-schizoaffective-disorder/.
Gunturu, S. “A Case Study of Frotteurism and Schizoaffective Disorder in a Young Male – an Atypical Association.” European Psychiatry, Elsevier Masson, 9 June 2015, www.sciencedirect.com/science/article/pii/S0924933815313614.
O'Connell, K L. “Schizoaffective Disorder: a Case Study.” Journal of Psychosocial Nursing and Mental Health Services., U.S. National Library of Medicine, Oct. 1995, www.ncbi.nlm.nih.gov/pubmed/8847672.
Soto, Joseph A De. “A Case Study: Treatment of Refractory Schizoaffective Disorder with Aripiprazole.” Journal of Pharmacy Technology, 1 May 2005, journals.sagepub.com/doi/abs/10.1177/875512250502100306.